One step endoscopic cysto-duodenostomy and endoscopic biliary drainage

Background: Pancreatic pseudocyst is a major complication of acute and chronic pancreatitis. Pancreatic pseudocysts show a wide variety of clinical presentations ranging from completely asymptomatic lesions to multiple pseudocysts with pancreatic and bile duct obstruction.

Common bile duct stricture is a frequent complication in chronic pancreatitis with a reported incidence of 3–23% and sometimes caused by a pancreatic pseudocyst in the head of the organ.

Because of relatively high mortality, morbidity and recurrence rates of surgical drainage, which is associated with long hospitalization, efforts have brought about percutaneous and endoscopic drainages.

Endoscopic techniques include transmural incision, transmural puncture and stenting, and transpapillary stenting. Transgastric or transduodenal drainages can be carried out depending on the proximity of the pseudocyst to the gastrointestinal lumen.

In the literature we have not found any case report about one step endoscopic cysto-duodenostomy and endoscopic biliary drainage.

Case report: The reported 53 years old male patient had chronic pancreatitis due to alcohol abuse. The latest acute relapse occured four years ago. Actually he presented in hospital because of weight-loss, abdominal discomfort, epigastrial pain after meal. Based on transabdominal ultrasound and CT we diagnosed pseudocyst in the head of the pancreas with a diameter of 75×67×73mm. The pseudocyst caused dislocation of the duodenum. The choledochus was 12mm large, without gallstone in it's lumen.

After transabdominal ultrasound guided diagnostical puncture of the pseudocyst, we have done ERCP. During duodenoscopy an impression was visualized in the duodenum. The Vater papilla seemed morphologically normal. On the distal and medial part of the choledochus an internal and the pseudocyst caused external stenosis were visualized. After complete endoscopic sphyncterotomy, we placed a 10 French biliary stent in the mean bile duct. After that, transmural cysto-duodenostomy was done. After dilatation, we placed an 8 French stent from the wall of duodenum into the cavity of pancreas pseudocyst. No complication has occured.

Conclusion: One step endoscopic cysto-duodenostomy and endoscopic biliary drainage is an effective and safe alternative of surgical drainage in case of pancreatic pseudocysts.